PATIENTS FOR PATIENT SAFETY Pilot PROJECT

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PATIENTS FOR PATIENT SAFETY Pilot PROJECT
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My Background

• Previously a lecturer in Social Work
• Chair of the Royal Brompton Harefield NHS Trust
  PPI Forum
• Sit on Trust Board with observer status, Audit
  and Risk Committee, Complaints Committee
  Equality and Diversity Committee
• Member of DOHs Information Clinical Governance
  Subgroups - Professional Regulation Patient
  Safety Programme
• Manager of the PfPS Project
• Just completing PhD on Medical Harm Patient
  Empowerment within the NHS
• WHO Patient Safety Champion
• Just appointed to a research post at Kings
  College in their Patient Safety Service Quality
  Research Centre

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Key Policy Drivers for PPI in Patient Safety

• Around the world, healthcare organisations that
  are most successful in patient safety are those
  that encourage close cooperation with patients
  and their families (Safety First, DOH2006).
• The report also recommends
• Each board should make it clear how they intend
  to ensure that patients carers play an integral
  part in all initiatives to introduce a patient
  safety culture change within the NHS (Rec 8)
• The active involvement of patients their
  families should be promoted by establishing a
  national network of patient champions who will
  work in partnership with NHS organisations
  other key players to improve patient safety (Rec
  13).

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Key Policy Drivers for PPI in Patient Safety

• There is a need to involve patients and the
  public in all aspects of planning, organisation
  and delivery of healthcare
• To be involved the public had to be empowered.
• E.g. given proper info to formulate views, be
  listened to and have views acted upon (Bristol
  Report 2001).

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Key Policy Drivers for PPI in Patient Safety

• There is an increasing recognition that patients
  should be seen not as passive recipients of
  healthcare interventions chosen delivered by
  health professionals, but as active participants
  with their own values beliefs. Patients
  carers therefore have a vital role to play both
  in helping to define what counts as quality in
  healthcare and in drawing attention to
  unacceptable standards of care (Safeguarding
  patients, HM Govt 2007- response to Shipman
  other inquiry reports).
• A specific duty on all organisations to involve
  patients/public in the planning development of
  services.
• (Section 11 of the Health Social Care Act 2001).

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Evidence of a Lack of PPI in Patient Safety

• Only 24 of Trusts routinely informed patients
  involved in a reported incident and 6 did not
  involve patients at all
• (House of Commons (2006) Select Committee on
  Public Accounts)

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Evidence of a Lack of PPI in Patient Safety

• The following reports found that PPI in clinical
  governance processes in hospital Trusts and
  Primary Care was limited.
• Achieving Improvements through Clinical
  Governance (NAO 2003).
• Improving Quality and Safety progress in
  implementing clinical governance in primary care.
  Lessons for the new Primary Care Trusts (NAO
  2007).

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Evidence of a Lack of PPI in Patient Safety

• In a review of strategies to involve patients in
  improving the quality of healthcare, the Picker
  Institute noted about patient safety that
• The UK has had a major programme to improve
  patient safety since 2001, but with little
  recognition of patients' potential to take an
  active role
• (Picker Institute 2007)

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Background to The Patients for Patient Safety
(PfPS) Pilot Project

• Joint initiative between the National Patient
  Safety Agency the charity, Action against
  Medical Accidents
• Aims to develop the role of patients and the
  public in patient safety work in the NHS
• Funded for two years by the NPSA from April 2006
  to March 2008
• Project Managers Josephine Ocloo and Louise
  Price

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Key Project Objectives

• To build a network of patients the public
  (including those affected by medical harm)
  wanting to be involved in patient safety work
  to develop good practice.
• Develop a core training module for network
  members on key aspects of patient safety
• Develop local strategies for PPI in patient
  safety by working with 2 NHS sites

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The Projects Methods

• To identify good practice egs of PPI in patient
  safety through letter to NHS Trusts
• Holding meetings with 4 NHS Trusts working
  closely with 2 in more depth
• Developing a Patient Safety Network for Patients
  the Public
• Running a Training Module for Patients the
  Public
• Holding 2 workshops with staff to explore their
  support needs

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Some Key Findings Trust A

• Some very serious PSIs had occurred over recent
  years, providing the momentum for looking at the
  way the Trust responded to such incidents
• The Trust eventually agreed to focus primarily on
  the area of suicide and to identify key issues
  and factors
• From the perspectives of relatives/carers
  bereaved through suicide
• From the perspectives of staff involved with the
  aftermath of a suicide and dealing directly with
  bereaved relatives, And
• To look at the implementation of the Being Open
  guidance when an incident occurred.

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Workshop with Patient Relatives and Carers

• 22 relatives identified by Trust for contact
• 2 relatives expressed interest in being involved
  (later contacted by a 3rd person)
• 2 relatives provided written accounts of their
  experience but did not wish to participate
• 3 said did not wish to be involved
• 15 did not respond unable to contact by
  telephone

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Possible reasons for non-response

• Families/carers unable to obtain resolution and
  closure
• Unresolved issues with the Trust
• No ongoing relationship with the Trust
• Patients/relatives feeling there is not going to
  be any personal benefit to them as a result of
  their input or that time/expenses will not be
  properly compensated
• Going back 3 years may have been a factor in
  being able to contact families
• How families are identified and the dangers of
  screening out those seen as too difficult to work
  with, whose experiences might well provide
  invaluable learning for the Trust.

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Strategies for the Future

• Might include
• Seeking the views of patients/relatives/carer's
  through individual interviews
• relatives invited more informally to share their
  experiences with staff or to attend a meeting
  with staff members
• Written stories.
• Involving people at risk of suicide carers.
  This might act as an incentive to get involved if
  it will help patients manage their own situation
  more effectively as well as helping others.

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Workshop With Staff After a Suicide

• Staff often devastated as often knew patient well
• Staff blamed themselves as felt might have
  prevented the suicide
• Staff feared being blamed by others, or through a
  formal inquiry
• Staff found involvement with families after a
  suicide exceptionally difficult because of high
  level of emotions/concerns involved concern
  about saying the wrong thing a fear of
  litigation
• Staff felt they or their colleagues often not
  offered enough support. But acknowledged they
  found it difficult to take up support if they
  thought it would put pressure on other staff

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Follow-up Workshop with Staff

• Key Aims
• To develop ways of supporting staff following a
  serious PSI
• Implementing Being Open guidance

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Follow-up Workshop with Staff Key findings

• Staff need space to debrief and reflect upon
  their feelings after an incident which can be
  facilitated in different ways deemed most
  appropriate by staff (through counselling, group
  support or one to one sessions with a supervisor.
  
• Staff felt not always properly informed on what
  was happening after an incident or interviewed
  and therefore could not properly and
  appropriately support relatives
• Staff/teams affected by an incident were not
  always part of a wider investigation or RCA
  analysis after an incident so did not know what
  was happening, about key outcomes and learning
  from PSI.

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Follow-up Workshop with Staff Implementing the
Being Open guidance.

• Staff wanted to know who was responsible for
  implementing Being Open and exactly how open they
  should be. For example who should give
  information to families/carers, how much and what
  type
• It was felt that this process needed to be
  clearer at team level, so that everyone knew 'who
  knew what' and 'who was doing/saying what.
• It was seen as important to involve families in
  any RCAs or investigations, for clarity on how
  this was done, who was doing it and feedback
  given to the staff team.

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Some Key Findings Trust B

• To explore a model for PPI in patient safety work
  based upon empowerment.
• To introduce another strand into the Trusts
  patient safety programme.
• To identify patients the public to become
  involved in the Trusts patient safety work.

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Empowering PPI in Patient Safety Key
Questions/Points from Launch Event

• Is an empowered patient a safer one?
• Partnership - The importance of seeing
  patient/carers as part of the team and their
  needs at its centre
• Addressing imbalances of power in patient/staff
  relationships
• How individuals can be made passive as patients
• Supporting staff as part of empowering patients

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Attempts at Empowerment

• The Hand Hygiene Project
• Working with those with a poor healthcare
  Experience (eg affected by a PSIs or who have
  made a Complaint)
• Workshop with Patient Governors

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Working with those with a Poor Healthcare
Experience Some Questions to Consider

• How do we feel about working with those with poor
  experiences of healthcare ?
• What are our fears about this involvement ?
• How can we address these fears ?
• What are the barriers in our Trust to this
  involvement ?
• How can we address these barriers in the future ?

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NPSA Model for Working with those Affected by Harm

• To not put patients and staff together too soon
  in the process
• Bring together a mixture of patients from
  different Trusts have a workshop off site
• Identify Trust area's most likely to cause harm
  to patients and then to select/profile patients
  according to these areas
• Draw upon voluntary/community sector to identify
  diverse patient groups
• Staff attending workshops there to listen only
  and not to defend the Trust
• Focus of the workshop is on learning rather than
  on accountability. This should not preclude
  patients from expressing what they think went
  wrong
• Independent facilitators are used
• Permission letters from patients to indicate if
  want further involvement
• Learning from workshops to be shared more broadly
  with Trust staff to see if stories resonate to
  allow for reframing clarification of the
  problem(s).

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Workshop with Governors on Developing PPI in
Patient Safety

• Some Points made
• Staff dont always hear
• Patients unable to make their points
• Need to understand role, function of committee
  and what is required of patients the public
• Jargon, language can be a problem
• Problems of tokenism not feeling valued
• Communication needs to be more two way and in
  partnership
• PPI reps need to be informed about follow-up
  action when involved
• PPI reps need to feel it is okay to challenge

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Tackling barriers to involvement on committees
Some guidelines

• Need for proper Induction
• Terms of reference of committee other relevant
  information should be given well in advance of
  meeting
• At least 2 patient reps should be invited to
  avoid tokenism
• Patient reps should be properly introduced to
  committee members
• Training should be offered if appropriate
• The meeting should be conducted without the use
  of unnecessary jargon or terms should be
  explained or the patient given info after the
  meeting
• Patient reps should be encouraged to participate
  in the discussion not be penalised if they
  challenge issues
• There should be proper reinbursement of expenses
  which might include travel, childcare for time
  incurred
• Reimbursement
• Action Proposal for patient representation on
  Risk Management Committee

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The Patient Safety Network

• Over the life of the project various meetings
  were held with PPI representatives on a range of
  issues to do with patient safety
• This included holding a 1day training event on
  patient safety, follow-up event on PPI in
  clinical governance 1 day conference on
  complaints/regulation the AHC
• Meetings were well attended by PPI
  representatives from patient forums, voluntary
  groups by individuals directly affected by
  medical harm.

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The Patient Safety Network Some Key Findings

• PPI representatives were well informed on health
  issues, but not on Trust Patient safety work
• Expressed a strong interest in safety, but viewed
  the safety agenda as about regulation
  accountability as well as learning improvement
• Were keen to get involved but needed proper help
  to do so, eg clarity on opps for involvement,
  info, training, expenses
• Wanted to see a partnership approach with h/care
  professionals where their views would be listened
  to, taken into account acted upon

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The Way Forward

• More needs to be done to develop a range of
  strategies for involving, supporting empowering
  patients/public in the patient safety agenda
• Involving learning from those with poor
  experiences of healthcare/ affected by PSIs is
  particularly important
• Staff need to be supported to work in partnership
  with patients/public

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Developing a Model for PPI in Patient Safety

• A starting point to think about PPI on different
  levels, with different strands
• Organisations should provide info on risks
  safety to the public, work with individual
  patients develop involvement at a strategic
  level

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Developing a Model for PPI in Patient Safety
Some Questions To Explore

• What are patient safety concerns within the
  organisation from patients perspectives?
• What are patient safety concerns within the
  organisation from staff perspectives?
• What are the key components of a patient safety
  culture in the organisation
• How can patients and the public engage with and
  be involved with this agenda and what are the
  barriers to this involvement?
• How might different groups be affected? Are
  people discriminated against and disempowered?
  What about those who have had adverse experiences
  of healthcare?

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Messages from Bristol

• The public are entitled to expect that means
  exist for them to become involved in the
  planning, organisation and delivery of
  healthcare
• For a healthcare service to be truly
  patient-centred it must be infused with the views
  and values of the public (as patients past,
  present or future). The public must be involved.
  To be involved, the public must be empowered
• (Bristol Report 2001 400)